Area 5 pinellas pediatric case report form (03-12).xls

Pediatric HIV/AIDS Confidential Case Report
(Patients < 13 years of age at time of diagnosis) I. HEALTH DEPT USE ONLY
Date Received at Health Department
Did this report initiate a new case investigation?
State Number
___ ___/ ___ ___/ ___ ___ ___ ___
Yes No Unknown
Document Source
Surveillance Method
Report Medium Field Visit Mailed Faxed Phone
A_____-_____-_____-____
Electronic Transfer CD/Disk
Report Status New Update Reporting Health Dept. City St. Petersburg
II. PATIENT IDENTIFIER INFORMATION-data not transmitted to CDC
Patient Name Last Name First Name Middle Name
State Zip Phone ( ) City/County Patient Number III. DEMOGRAPHIC INFORMATION-complete ALL fields
Diagnostic Status Perinatal HIV Exposure Pediatric HIV Pediatric AIDS Pediatric Seroreverter
Sex assigned at Birth Male Female
Date of Birth __ __/__ __/__ __ __ __
Status Alive Dead
Country of Birth US Other (specify):
Date of Death ___ ___/___ ___/___ ___ ___ ___
State/Territory of Death _________________________________
Ethnicity (select one): Hispanic/Latino Not Hispanic/Latino Unknown
Race: (select all that apply) Black/AA Asian Native American or Alaskan White Hawaiian/PI Unknown
Residence at Diagnosis: Same as Current Street Address:
City: County: State/Country: Zip:
IV. FACILITY OF DIAGNOSIS
V. PATIENT HISTORY- complete ALL fields
Preceding the first positive HIV antibody test or AIDS diagnosis, the child's biological mother had (Respond to ALL Categories)
HETEROSEXUAL relations with any of the following:
Intravenous/Injection Drug User……………………………………………….
City: Bisexual male …………………………………… Transfusion recipient with documented HIV infection……………………….
Transplant recipient with documented HIV infection………………………… Person with AIDS or documented HIV infection, risk unspecified…………. Received transfusion of blood/blood components (other than clotting factor) First Date:____/____/____ Last Date:____/____/____ Received transplant of tissue/organs or artificial insemination Preceding the first positive HIV antibody test or AIDS diagnosis, the child had Received clotting factor for hemophilia/coagulation disorder Specify Clotting Date received (mm/dd/yyyy) Received transfusion of blood/blood components (other than clotting factor) First Date:____/____/____ Last Date:____/____/____ Received transplant of tissue/organs Is transplant or artificial insemination being investigated or considered Is pediatric sexual contact being investigated or considered as primary mode of exposure Is pediatric sexual contact being investigated or considered as primary mode of exposure Is other exposure being investigated or considered as primary mode of exposure Child's biological mother's HIV infection status: Known to be uninfected after this child's birth Date of mother's first positive HIV confirmatory test Was the biological mother counseled about HIV testing during this pregnancy, labor or delivery? (mm/dd/yyyy) IX. TREATMENT/SERVICES REFERRALS
Neonatal zidovudine (ZDV, AZT) for HIV prevention Other neonatal anti-retroviral medication for HIV prevention If Yes, specify the medications:
Anti-retroviral therapy for HIV treatment This child's primary □ Biological parents □ Foster/adoptive parent, relative □ Social service agency □ Unknown
caretaker is: □ Other relative □ Foster/adoptive parent, unrelated □ Other (if Other, please specify):
VI. LABORATORY DATA
HIV Antibody Tests at Diagnosis (Indicate first test - mm/dd/yyyy)
HIV Detection Tests: (Record earliest test-mm/dd/yyyy)
Viral Load Test: ( most recent test- mm/dd/yyyy)
Immunologic Lab Test: (test date-mm/dd/yyyy)
At or closest to current diagnostic status CD4 Count:____________ cells/ul (________%) First<200 or <14% of total lymphocytes
CD4 Count:____________ cells/ul (________%) HIV-1 RNA OtherWas patient confirmed by a physician as:HIV- infected □ Yes □ No □ Unknown If Yes, enter date of diagnosis (mm/dd/yyyy)
Not HIV- infected □ Yes □ No □ Unknown If Yes, enter date of diagnosis (mm/dd/yyyy)
VII. CLINICAL STATUS
Clinical Record Reviewed? □ Yes □ No
Bacterial infection, multiple or recurrent (including ___/___/____ □ □
Lymphoid interstitial pneumonia and/or pulmonary ___/___/____ □
□ □ Lymphoma, Burkitt's (or equivalent)
___/___/____ □
Coccidioidomycosis, disseminated or extrapulmonary ___/___/____ ___/___/____ □
___/___/____ □
Mycobacterium avium complex or M. kansasii, Cryptosporidiosis, chronic intestinal (>1 mo. duration) Cytomegalovirus disease (other than in liver, spleen, or M. tuberculosis, disseminated, or extrapulmonary ___/___/____ □ □
*Mycobacterium, of other species or unidentified Cytomegalovirus retinitis (with loss of vision) ___/___/____ □ □
Herpes simplex: chronic ulcer(s) (>1 mo. duration); or bronchitis, pneumonitis or esophagitis onset>1 mo of age Progressive multifocal leukoencephalopathy ___/___/____ □
Histoplasmosis, disseminated, or extrapulmonary ___/___/____ □
Toxoplasmosis of brain, onset at >1 mo of age ___/___/____ □ □
Isosporiasis, chronic intestinal (>1 mo. duration) ___/___/____ □
Has the child been diagnosed with pulmonary tuberculosis? If Yes, initial diagnosis and date
□ TB pre- 1993 □ Definitive □ Presumptive □ Unknown (mm/dd/yyyy) VIII. BIRTH HISTORY (for PERINATAL cases only)
If No or Unknown, do not complete this section.
Residence at Birth: □ Same Address as patient address Address:
City: County: State/Country: Zip:
Hospital at Birth: Facility Name: Phone No: ( ) -
Address: City: County: State/Country: Zip:
Birth weight Birth Type □ Single □ Twin □ > 2 □ Unknown
enter lbs/oz OR grams
Birth Delivery □ Vaginal □ Elective Caesarean □ Non-elective Caesarean □ Caesarean, Unk type □ Unk If Yes, specify types and enter codes, if known:
Prenatal Care- Month of pregnancy when prenatal care began: Prenatal Care- Total number of prenatal care visits Did mother receive zidovudine (ZDV, AZT) during pregnancy? If Yes, week of pregnancy when zidovudine (ZDV, AZT) began: Week ____________
Did mother receive zidovudine (ZDV, AZT) during labor/delivery? Did mother receive zidovudine (ZDV, AZT) prior to this pregnancy? Did mother receive any other antiretroviral medication during pregnancy? If Yes, specify:
Did mother receive any other antiretroviral medication during labor/delivery?
X. LOCAL FIELDS (health department use only)
HEPATITIS: A____ B____ C____ Other____ Unknown_____
Link with eHARS stateno(s):
NIR STATUS: NIR_OP______ NIR OP DATE______________
EPF____ EPF DATE_____________
NIR_ CL______ NIR CL DATE________________
OTHER RISKS: A____ B/C____ D____ F____ M____ V____ J____
NIR_RE_______ NIR RE DATE____________ Initials (3)________
SOURCE CODE A__________
XI. COMMENTS (e.g. birth mother history on drug use, STDs, mental illness, jail history, father, siblings, etc.)

Source: http://www.pinellashealth.net/HIVAIDS/2012_Area_5_pediatric_HIV-AIDS_web_CRF.pdf